Chapter 17
HUMAN RESOURCES FOR HEALTH
Ritika Tiwari, Nomvula Marawa, Eric Buch, Usuf Chikte
Introduction
The chapter touches on the previous national Human Resources for Health (HRH) strategy, launched in 2011, reviews progress with implementation of HRH interventions and reflects on the likely implications for HRH of future health system reforms, in particular the National Health Insurance (NHI) Bill. The chapter then reviews the problems related to inadequate HRH data for planning and monitoring progress. The implications for formalisation of Community Health Workers (CHWs) are considered, as is progress in strengthening leadership across the health system. A summary of the recently completed HRH strategy is provided. Some of the main HRH challenges are outlined, including dealing with the consequences of the COVID-19 crisis.
Global and Regional Developments in HRH
In 2016, the Global Strategy on Human Resources for Health: Workforce 2030 was adopted by the 69th World Health Assembly (WHA69.19), which explicitly highlighted equitable access to health workers. This was followed by the report of the United Nations High-Level Commission on Health Employment and Economic Growth (HEEG) in September 20161, which highlighted that investments in education and job creation within the health and social sectors result in a triple return of improved health outcomes, global health security, and inclusive economic growth. The HEEG report made the following recommendations:
(1)stimulate investments in creating health sector jobs (for women and youth) with the right skills, numbers and location;
(2)maximise women’s economic participation and foster their empowerment through leadership and addressing gender biases and inequities in education and the health labour market;
(3) scale up transformative, high-quality education and lifelong learning to match skills with the health needs of populations;
(4) reform service models that focus on hospital care and focus on underserved areas;
(5) harness the power of cost-effective information and communication technologies to enhance health education, services and information systems;
(6) ensure investment in the International Health Regulations core capacities with skills development of national and international health workers along with protection and security of all health workers and facilities.
The plan proposes goals and the strategic approach and activities with which the International Labour Organization (ILO), Organisation for Economic Co-operation and Development (OECD) and World Health Organization (WHO) can support and facilitate country-driven implementation of the Commission’s recommendations, reinforce the implementation of the Global Strategy on Human Resources for Health: Workforce 2030, and concomitantly optimise the path for achieving the 2030 Agenda for Sustainable Development, including Universal Health Coverage (UHC).
However, there has been limited progress on HRH globally and the world’s health workers bear undue impact of the pandemic. It has only become more evident how critical the health workforce is to health systems and achieving improved coverage. Additionally, simple availability of health workers does not ensure accessibility. It is only when there are enough health workers who are adequately skilled and equipped (with right tools and technologies), equitably distributed and who are motivated and empowered to deliver quality health care that is appropriate, that they adequately support the health system.
National Strategy on Human Resources for Health in South Africa
In 2011, the Minister of Health launched the South African Human Resources for Health (HRH) Strategy for the Health Sector 2012/13–2016/17. She stated: ‘Improving human resource planning, development and management is instrumental in the overhaul of the health system. It is a strategic intervention whose activities will contribute significantly to improved health outcomes. Compensation of employees is one of the biggest cost drivers in any institution ... Therefore, as the most expensive asset, we have to manage human resources prudently ... this means that the health sector has to be staffed by an appropriately skilled workforce that is able to respond to the burden of disease and citizens’ expectations of quality service’ 2
HRH planning, estimation and forecasting
HRH planning is intricate because it is dependent on a range of factors, including what services need to be provided (e.g., community vs facility-based; fixed vs mobile) and how and who will provide them and what skills are required. HRH planning, estimation and forecasting is crucial to planning training pipelines, service delivery and budgets, each of which comes with challenges. Planning of training pipelines is difficult due to the long lead times to graduate professionals, interdigitating with the choices on scope of practice, the changing epidemiology and technology and the rate of turnover of staff. Projections of the total numbers per category required and their unit costs are important for budgeting purposes. The way in which wages are set or determined is a crucial consideration which affects government’s control over unit costs. Planning
numbers faces the complexity in giving empirical content to health needs. Benchmarks or standards and norms are therefore often used in HRH planning to provide comparators for adequate provisioning. Ono et al. have found that the Netherlands, Australia, United Kingdom and especially Japan are incomparable in their HRH planning, data collection approaches, and models used.3 However, their conclusions are not generalisable to South Africa. The usefulness for South Africa of the few documented HR planning case studies and literature from comparable peer countries, such as other African or upper-middle-income countries3 has been contested, as such ratios are always conditional on modes of delivery and services packages. However, local and context-specific engagement on adequate health worker ratios, which involves multiple stakeholders and experts can overcome this problem. The wide disparities in vulnerability and remoteness between South African communities should lead to some variation based on the community.
In the quinquennium under review there was important formative work on HRH planning, estimating need and forecasting, particularly in the preparation of the South African HRH Strategy 2030.
Data sources for HRH planning in South Africa
Reliable data is essential for effective HRH planning. While there are several sources that have databases available for the health workforce in South Africa, unfortunately none are complete (Table 17.1). Thus, an HRH planning exercise may require compilation and analysis of more than one database. A big challenge is that, barring the Statistics South Africa population statistics, none of the databases are available in the public domain. In the 2015–2020 quinquennium an initiative to merge data sources into a useable tool was initiated.
Table17.1 Available data sources for HRH planning in South Africa
Data Sources
Health Professions
Council of South Africa (HPCSA)4 and other professional councils
Personnel and Salaries management system (PERSAL)
Board of Healthcare Funders (BHF)
Colleges of Medicine of SA (CMSA)
Council for Medical Schemes (CMS)
District Health Information System (DHIS)
Demographic and Health Surveys (DHS)
National Income Dynamics Survey (NIDS)
Registration data of health workforce – Age, location, race, gender, etc.
Government payroll information
Practice numbers (enabling health care providers to claim from health funders)
Public–private split absent. Includes non-practicing professionals and those overseas
Does not identify any field of specialisation
No other HRH data
Examination data on specialist fellowships. Includes demographic data --
Information on use of professionals in the private sector
Information on nurse workloads, hospital volumes and disease profiles
Helpful for population health needs and for triangulation of visits
Data on factors such as visits to clinics, and private sector consultations
Data Sources
Department of Higher Education and Training (DHET)
Stats SA – General Household Survey (GHS)
Stats SA – Population Statistics5
Data on number of enrolments and graduates
Social determinants of health; access and use of health services
Demographic indicators
HRH performance studies
The HRH planning studies that have been undertaken previously tended to be limited to a few major health workforce categories, such as doctors, medical specialists, CHWs and nurses (Table 17.2). There has been no study estimating or forecasting the entire health workforce of South Africa (especially not for the support staff such as cleaners, laboratory technicians and ambulance drivers).
Table17.2 HRH studies undertaken in South Africa
Title of studies Year Health worker disciplines considered
Human Resources for Health in South Africa –A draft strategy
Updated General Practitioner (GP) and Specialist Numbers for SA
The Human Resource Supply Constraint: The Case of Doctors
The Human Resource Supply Constraint: The Case of Nurses
Human Resources for Health South Africa (HRH Strategy for the Health Sector: 2012/13 –2016/17)6
Staffing Norms for Primary Health Care in the context of PHC Re-engineering
National Tertiary Health Services Plan and Clinical Teaching and Training of Health Professionals
Implementation guideline of health workforce normative guides and standards for fixed PHC facilities
2001 Nursing, dietetics, pharmacy, radiography, laboratory, physiotherapy, occupational therapy, dental, social work
Primary Strategy
2010 GPs, Specialists All levels Estimate
2010 Medical Specialists, Medical
levels Forecast
2010 Registered and Enrolled nurses and Nursing assistants All levels Forecast
2011 Medical, Medical Specialists, Dental, Nurses Community health and home-based workers
2012 Medical Specialists, Medical Nursing Counsellors, Pharmacy Admin support
2013 Infrastructure and health facility based: Pop/Consult Room, Hospitals – Public, Hospitals – Private, Beds – Public, Beds – Private
2015 Medical Nurses, Nursing, Pharmacy, Dental Clinical Associate, Admin support, Operational Facility Manager, Counsellor, Groundsman, Security, Cleaner
All levels Estimate + Forecast
Primary Estimate + Forecast
Tertiary Estimate + Forecast
Primary Normative Guidelines Human
Title of studies
Medical specialist planning Report with results for reference group input
2030 Human Resources for Health Strategy: Investing in the Health Workforce for Universal Health Coverage
2019 Medical Specialists by discipline Tertiary Estimate + Forecast
2020 Plan 1: Medical specialists, Medical, Dental, Nursing, Pharmacy, Occupational therapy, Physiotherapy, Psychology, Radiography, Environmental health, Clinical associates
Plan 2. Primary health care workers
Plan 3. Medical specialists
Estimate + Forecast
There have been huge transitions in the journey of HRH estimation and forecasting in South Africa, beginning with the report of the HRH Task Team chaired by Professor William Pick (2000) to the current WISN Tool which has been gazetted by the South African government.
Workload Indicators of Staffing Needs (WISN)
The WISN tool was developed by the WHO to determine staffing norms. The National Department of Health (NDoH) is currently using WISN for developing and implementing health workforce staffing norms and standards for health facilities7. In 2017, the NDoH reported that the activity standards for district hospitals had been completed7. However, the NDoH was unable to meet its target of approving HRH norms for district and specialised hospitals due to the unavailability of data on district hospital service activities7. Failure to set HRH norms for district and specialised hospitals in turn affected the development of HRH norms for regional, tertiary and central hospitals7. Furthermore, the WISN approach seems to be the only method adopted by the NDoH for HRH planning, but several limitations have been reportedon its methodology. These limitations include dependence on the accuracy of annual service statistics used to assess workloads; possible overreporting of annual service statistics; inability to differentiate when the same activity is performed by two different staff categories; and insufficient consideration of the unique circumstances and HRH needs in rural areas8–10. Nonetheless, the WISN has identified the shortfalls in PHC staff in South Africa. In line with proposals from some health economists, it may be more appropriate to use a combination of integrated needs-based HRH planning methods. These methods should include consideration of: demographic and epidemiological changes; impact of health policies on service delivery; quality and equity; prioritisation of underserved areas; workforce and health expenditure; level of services; and the productivity of health care workers11–13
The non-generalisability of WISN may be affected by the topography, climate, and population densities of different areas14, 15. Wrong decision-making based on WISN results may also pose an impact. In certain health facilities, due to a lighter workload – WISN calculations may show lower need for the health staff. Moreover, if service statistics are incomplete, human resource needs will be under-estimated. Furthermore, given the changing environment and its impact on health programmes, factors such as emergence of new tasks and services should also be considered in the calculation of human resources needed16 and the norm obtained should be reviewed as
far as possible17. Additionally, as reported by Smith et al.18, work has been done to value the cost South Africa’s PHC system using WISN to determine the mix and number of staff. Staffing levels that comply with WISN requirements are very low (7% of clinics in March 2016)19. A study done by the Medical Research Council (MRC) in North West province found the WISN model to be significantly more expensive than norms suggested by the MRC. This example illustrates the importance of linking staffing norms to broader HRH planning processes and modelling20. Thus, South Africa implemented WISN for PHC workforce planning but found the skills mix and staff determinations to be unaffordable due to the financial, infrastructure and technical challenges associated with WISN21
Task shifting/ Skills mix
Most of the HRH models prepared in South Africa have included factors which impact the productivity of physicians, including technological changes. In recent years, some HRH models have started to account for task-shifting, for example, substitution of doctors by mid-level staff such as nurses or trained assistants (called clinical associates in South Africa)22. Foreseeing South Africa’s shortage of medical professionals, these substitutions are very relevant when planning for NHI. Task shifting may mean that the production of mid-level health workers needs to be increased, some new cadres created, or the scope of existing cadres expanded.
Migration
Health workforce planning needs to take migration into account. Labonte et al. (2015) found that there has been an overall decrease in emigration of skilled health workers from South Africa since the early 2000s, driven by a reduced need for foreign-trained skilled health workers in destination countries, including generalist and specialist doctors, nurses, dentists and pharmacists23. However, 10% of the survey sample reported that they were very likely to migrate within the next two years. This migratory intent varied by professional groups – 60% of dentists and just over 40% of nurses reported some likelihood of seeking work in another country within the next five years23. One-third of survey respondents were return migrants, showcasing the concept of ‘circular migration’ as discussed in previous studies24, 25 .
Public spending
Public spending is calculated using spending by government expenditure and schemes, social health insurance and private insurance. The OECD reported in 2020 that more than 70% of health spending across OECD countries was funded from public sources. On average, 8.8% of Gross Domestic Product was dedicated to health in 2018. Countries such as Columbia (74%) and Chile (60%) had higher proportional expenditure through government/compulsory schemes than South Africa at 43%26 Thus, in South Africa where government provides subsidies for voluntary health insurers, the proportion of total spending from public sources is higher (54%) than government/compulsory schemes (43%)26. In South Africa there has been an increase of 53% in overall provincial and local government health expenditure from R100 759 million in FY2011/12 to R215 755 million in 2020/21. The annual average increase over the past nine years has been 8.8%27. (See Chapter on Health Financing for more detail.)
The health workforce inequities at several levels in South Africa were stark and the workforce inequity between the public and private health sectors is projected to worsen without concerted policy intervention. For example, the overall national density of medical specialists was calculated as 16.5 per 100 000. However, there are an estimated seven specialists per 100 000 user population employed in the public sector and 69 per 100 000 in the private health sector. There are also inequities within the public health sector. Rural provinces have significantly lower densities of more skilled health professionals. The inequities for medical specialists, nurses and CHWs are marked. For example, the Western Cape has 25.8 medical specialists per 100 000 public sector population compared to only 1.4 per 100 000 in Limpopo. Although the location of public sector tertiary and central hospitals influence this maldistribution, in practice this means that accessing specialist services in Limpopo is extremely difficult in comparison to other provinces28.
The urban–rural inequalities in the health workforce also deny equitable access to health care in South Africa, mostly discriminating against the poor29. The disparities vary in urban areas, while resourcing is consistently poorer in rural areas29 Furthermore, the shortage of drugs, equipment and infrastructure often mitigate against attracting highly trained professionals to rural and underserved urban areas30.
The provincial inequalities in health worker densities also reflect the variation in skills mix across the country. The public health sector in South Africa is predominantly nurse-driven, with nurses making up 56% of health care providers, reaching 63.9% in the Eastern Cape. While medical doctors constitute around 8.6% of the public health workforce, the proportions are lower in Limpopo (4.3%), Mpumalanga (6.1%) and the North West (6.1%), but higher in Gauteng (11.6%) and the Western Cape (14.6%). CHWs play a critical role in the health systems of the Northern Cape (36.8%), Mpumalanga (35.3%), North West (34.9%) and Limpopo (31.1%), as compared to lower proportions in more urbanised provinces (Eastern Cape – 14%, Western Cape –15%, KwaZulu-Natal – 18%, Free State – 19%, Gauteng – 19%). The maldistribution of health workers within provinces by district and level of care requires further analysis and policy attention28
Status of the health workforce
Public
spending
There has been an overall increase in the number of doctors who have been trained in the last two decades in South Africa. The HPCSA registrations show an increase from 21 378 doctors (2000) to 46 420 (2020), an overall increase of 117%.
There was a 31.1% increase in the South African population over this period, during which the ratio of male doctors per 10 000 population only increased from 3.52 in 2000 to 4.69 in 201931, compared to an increase in female doctors per 10 000 population from 1.25 in 2000 to 3.21 in 201931
The recently completed National HRH Strategy 2030 provided a more detailed breakdown of the current ratios of health practitioners in South Africa, including projections of needs into the future28. Most of the ratios show impressive gains since the 2011 HRH Strategy, although this may in part be due to higher levels of inclusion in the PERSAL HR information system. (See Chapter on Health Financing for more discussion of this.)
Table17.3 2019 Public sector health workforce – Inter-provincial variation in staffing ratios per 100 000 public sector population
Source: PERSAL32 for all the selected categories except CHWs, which were obtained from the CHW register, as reported in the DHB 2017/1833
Population: Calculated from Thembisa model34, StatsSA GHS35
Occupation Specific Dispensation (OSD)
An OSD for remuneration was introduced in 2007 for public sector employees in South Africa in an effort to better recruit, retain and motivate professionals for public service. Each identified occupation has its own differentiated OSD scales to cater for the unique needs of an occupation, prescribing job grading, structures and job profiles to eliminate inter-provincial variations. The OSD also provides clear salary progression and career-pathing opportunities36. While the salaries are lower than in advanced industrial countries, OSD has closed this gap but widened the gap with African countries37. Questions have been raised about how effective OSD has been to drive commitment in health professionals to public service.
Compulsory
community service
Compulsory community service of 12 months was introduced in 1998 for health professionals, starting with medical practitioners38 so that those who had benefitted from state largesse (government heavily subsidises health professional education) could offer a period of service back to where the needs are greatest. Community service is required before full professional registration can be obtained. The experience of community service for doctors over the first one-and-a-half decades was successful and largely met its original objectives of redistribution of health professionals
and professional development39. Community service requires more attention to orientation, management support and clinical supervision, and a focus on professional development opportunities38. Additionally, it has been suggested that community service initiatives should integrate mental health into PHC for decentralising mental health services40. While the benefits have been shown, the community service programme has been subjected to immense funding pressure, with under allocation of provincial resources to support the increased number of health professional graduates.
Community Health Workers
Globally, CHW programmes gained prominence in the 1970s with WHO’s Declaration of Alma-Ata, which saw CHWs as a key mode of delivery for PHC and as a strategy to expand the supply of health care workers. In many low- and middle-income countries, CHW programmes have been driven by non-governmental organisations (NGOs) reaching the doorstep of marginalised and rural populations.
The evidence of the effectiveness of CHW programmes is based on cost-benefit analyses and randomised control trials of CHW programmes on child and maternal health, or communicable diseases or single health issues. More recent evidence suggests that programmes designed around multiple health issues may be more cost-effective and better suited for the multiple disease burden of low-income and middle-income countries. The studies highlight design and implementation issues that hinder CHW programmes from reaching their expected outcomes, namely: under-resourcing, affordability, short and varied quality of training, inadequate integration with the formal health system, poor management and supervision practices, and an informal CHW workforce that is often subjected to unfavourable working conditions. However, in several other countries such as Ghana (unpaid) and Rwanda (not entitled to salary), the remuneration levels would not be at this level41
The experience with CHW programmes in South Africa echoes that of other low-income and middle-income countries. There were few CHW programmes until a rapid upscaling of AIDS-focussed NGO programmes. In 2011, the NDoH shifted to a comprehensive CHW policy focus on the disease burden presented by HIV/ AIDS and TB, maternal and child health42. There is strong emerging evidence of the effectiveness of CHWs43. However, there is also evidence that policy-makers need to contend with career pathing, variation in educational qualifications and training, retention, leadership and governance issues. There has been important progress in this regard with the formalisation of CHW programmes into the public sector, providing better salaries and job security.
Moreover, large-scale, comprehensive CHW programmes have been introduction in the context of implementing UHC, which has improved access to social support and health services at household and population level43. CHWs provide a range of health and psychosocial services in households and poor communities, especially in support of maternal and child health (MCH) services; TB, HIV/AIDS; and core areas of health promotion for nutrition, sanitation, and healthy living in South Africa44.
Nelson Mandela - Fidel Castro Medical Collaboration Programme
Diplomatic relations between South Africa and Cuba resulted in a bilateral agreement to establish the Nelson Mandela - Fidel Castro medical student training programme in 1994, aiming to promote PHC45. The programme began in 1996. In 2012, the programme was rapidly scaled up and peaked when 1 000 students were sent to study in Cuba. At that stage South Africa’s eight medical schools were graduating about 1 200 doctors a year. Experience with the programme showed that the medical students should be better supported for ease of transition into the local settings via a well-structured orientation and intervention programme in clinical skills46. This led to greater involvement of the South African Committee of Deans and provincial representatives. While the benefits of the increased medical training are not in question, there have been suggestions that at least some of the funds might have been better spent on increasing local capacity to scale up medical training47
Response to COVID-19 and mental health stresses on health workers
During the COVID-19 crisis, health workers faced several consequences including mental health stresses. It is evident that to build a resilient workforce, occupational and environmental factors must be addressed. Therefore, the psychological well-being of the health workers continues to be a priority. Female nurses being in close contact with COVID-19 patients had the most to gain from efforts aimed at supporting psychological well-being. Further research including on social care workers and analysis of wider societal structural factors is recommended48. (See Chapter on Mental Health for more discussion of this topic.) Due to increased workplace stress and vulnerability associated with working during the COVID-19 pandemic, South Africa’s health care workers experienced anxiety, depression, burnout, resilience and coping strategies during lockdown levels 2 and 349
Moving HRH towards the centre of health systems: needs, dilemmas and strategies
Health is a labour-intensive, labour-dependent sector. Without sufficient health workers who are well trained, supported and distributed a health system cannot be successful. It is therefore imperative that HRH is moved towards the centre of health systems development. There has been movement on this over the past quinquennium, but this momentum must not be lost.
NHI and Human Resources for Health Planning
It is important with massive reforms to begin with the end in mind. The NHI Bill describes what the NHI will look like. Health planners and managers need to document what the starting point is and plot the voyage to that destination. This includes estimating how long it will take, what it will it cost, how the money will flow, and a host of other institutional and service delivery issues.
The essence of the NHI Bill is that there will be ONE health system for everyone, albeit with many parts and that everyone who lives in South Afr ica will have access to the system, irrespective of ability to pay, and appropriate care for their needs. This means that HRH planning needs to be reworked for the requirements of the NHI and will need to revisit the number of health workers and skills mix required, scale up education given the long lead times to produce professionals and plan for improved workplaces and better distribution. This includes addressing the public–private dichotomy.
Under the NHI, the fragmented, poor, inefficient, understaffed and ill-equipped public sector (serving about 85% of the population) and the fragmented, over-serviced, over-specialised, expensive private sector (serving about 15% of the population) will together serve 100% of the population. This huge reform requires both systemic change and local change. These are many and complex and will take place over many years until 2030, including in HRH. A start has been made and HRH needs to be at the centre of this planning and evolution.
Quality national and sub-national data on the health workforce is a pre-requisite for developing evidence-informed policy. Most governments face challenges in reporting and publishing a full account of their HRH situation50. As in South Africa, the information is often dispersed and there are capacity constraints in data collection, analysis and utilisation. Governments do engage in multiple efforts and partnerships to improve minimum, inter-operable data sets; enable their national authorities to develop strategic intelligence on HRH; and to inform health workforce projections in relation to population needs and health systems priorities50. The efforts to do this in South Africa are evolving and should result in the development of National Health Workforce Accounts (NHWA) to improve the availability, quality and use of data on the health workforce through monitoring of a set of indicators to support achievement of UHC, Sustainable Development Goals (SDGs) and other health objectives. There is a need for developing and maintaining health workforce data sources such as the National Census, Labour Force Surveys and key administrative national and regional sources50
Presidential Health Summit
The Presidential Health Summit (2018) brought together key stakeholders from a wide range of constituencies in the health sector to deliberate and propose solutions to address the challenges facing the South African health system. The summit realised some practical, prioritised and realistic action plans with immediate, short-term and medium-term interventions. The HRH actions included a Review of Remuneration of Work Outside Public Sector (RWOPS) and validation and optimisation of the Integrated Human Resource, Personnel and Salary System (PERSAL) and HR management information systems, and most importantly, that staffing and funding policy must meet the needs of the health system51. The summit recognised that HRH challenges of governance and control hamper implementation of HRH plans and strategies and that provincial processes on allocation of funds also work against central planning and prioritisation, including issues with provincial budget negotiations resulting in poor provinces performing badly. The lack of a planning unit that works in collaboration with intergovernmental departments, such as the
Department of Labour, Treasury, NDoH, HPCSA and the Job Seekers Exemption Certificate (JSEC) (medical training planning committee) are hamstrung due to lack of a comprehensive HRH model. The summit was able to garner unanimous support for the implementation of NHI including universal quality health care, social solidarity and equity in health access52 and HRH planning and interventions should be geared towards this.
Health Market Inquiry (HMI)
In 2014, the Competition Commission of South Africa instituted a market inquiry into the South African private health sector in order to ascertain whether there were features preventing, distorting or restricting competition53. (See Chapter on Health Financing for more discussion of the HMI.) The final 2019 HMI Report flagged a range of regulatory and systemic issues that need to be addressed, including key HRH-related challenges. These include the disparity in the availability of specialists and general medical practitioners between the public and private health sectors, and between rural and urban communities54. The Commission made recommendations regarding the payment models and structure of private health care that need to be addressed to achieve greater equity. The report also identified concerns regarding the market power of health practitioners, incentives and relationships that may drive the high costs in the private sector. The report also mentioned that three big companies dominated the South Africa job market by offering doctors, who have admission rights over patients, attractive opportunities to practise in their facilities, thus indirectly influencing admission rates53
No accurate database exists on the number of practitioners active in the private sector. Using claims data, the HMI reaffirmed the challenges of the distribution and structure of private medical practice. The HMI found that there are 1.75 private practitioners per 1 000 insured population. While general practitioners are evenly distributed across the insured population (just under 1 per 1 000), specialists are concentrated in provincial capitals and metropolitan areas54. Most doctors work in solo practices, except for single-discipline group practices, such as radiologists, some anaesthetists, and corporate pathology groups. Multidisciplinary groups that allow for up- and down-referral are notable by their absence and the framework that serves as an impediment to this needs to be addressed. This kind of organised care is not well supported by funders and some practitioner associations and is limited by the current HPCSA ethical rules54
Research
The value of research in HRH to support policy-making and operational success needs to be understood and acknowledged through increased funding to enable the small pool of HRH researchers in South Africa to grow. New avenues of research need to be opened up.
There is a need for explanatory research to examine the roles and responsibilities of each category of health workers and determine who is defined as a health worker, in addition to research efforts that seek to descriptively count health workers in a more inclusive manner55
There is also a need for research to conceptualise the important aspects of social relations that may otherwise be hard to recognise, and how to measure and address these56, for instance, the lack of gender disaggregated data57. The science of HRH, which offers a deeper understanding of how UHC and the SDGs are dependent on health workers, has the potential to overcome outdated and ineffective orthodoxy about health workers globally57.
Leadership and management
Strategic leadership capability for the health workforce is essential, and there are many examples of innovation and good practices in the health system. However, leadership competency gaps remain at all levels of the health system and there are shortfalls in strategic, technical and managerial competence, capability and accountability. The prevailing health system culture acts as a barrier to the new styles of leadership needed. Gaps in ethical and values-based leadership contribute to poor quality of care through lack of accountability, corruption and fraud58. This prevailing management culture reflects the strong emphasis on centralisation, compliance, adherence to centrally determined processes, rigid classification of tasks, and an entrenched hierarchy. Consequently, there is a reluctance to question higher authority. These mitigate against decentralisation, individual agency, innovation, active engagement, and accountability. Consequently, many health leaders and managers feel unsupported, isolated and unprepared, with reportedly high levels of burnout, stress, low morale and poor motivation impacting staff, especially at the frontline of service delivery59
People management is a core function, yet HRH management practices tend to be weak, with wide variations across provincial health departments and insufficient accountability. Underlying these broader HRH management shortcomings is the limited state of readiness of national and provincial HRH divisions for both strategic and technical functions, with insufficient numbers of competent managers, a general low prioritisation of strategic HR within health departments and the persistent narrowing of HRH to a mainly administrative and operational function with little strategic and decision-making authority.
South Africa has numerous laws, well-established frameworks, policies and procedures that guide the governance, leadership and management of the health system and its human resources. However, the implementation of these remains sub-optimal. Health systems and HRH governance, leadership and management are priority areas that will determine the effectiveness and functioning of South Africa’s health system, and its outcomes. Although two-thirds or R133 billion of the public health sector budget is spent on the health workforce, limited attention is given to its optimal governance, planning, financing and management. At national and provincial government levels, more attention is needed on how this monetary investment translates into measurable gains, implementation efficiencies, and improved health outcomes28
Health service managers
The lack of management capacity within the public sector indicates a great need for further development of managers, and provinces need to identify managers who need training and make resources available for such60. The capacity to provide such programmes has grown but requires support to ensure their sustainability. The NDoH identified the training of managers of public hospitals for improving efficiency in health service delivery. Thus, the NDoH in collaboration with the universities of KwaZulu-Natal and the Witwatersrand launched a Master’s programme to train hospital managers61. The majority of the participants from this programme are working in the public health sector61
Gender equity in medical workforce
In a workforce forecasting exercise undertaken in 2021, it was estimated that if the status quo is maintained for male doctors (namely, 4.69 per 10 000 population), then by 2030 it will have increased to 4.76 per 10 000 population. In contract, if the status quo is maintained in the production of female doctors (namely, 3.21 per 10 000 population), then by 2030 the density of female doctors will increase to 4.35 per 10 000 population. However, if an attempt is made to achieve equity with male doctors, then an additional 2 242 female doctors will be needed by 203031 (Table 17.4).
Table17.4 Medical Specialists in South Africa (gender breakup)31 in 2019
The number of women undertaking CMSA examinations for sub-specialists is consistent. However, the trend for African sub-specialists is increasing as compared to other population groups (Table 17.5).
Table17.5 Demographics of sub-specialists who were successful in colleges of medicine examinations in South Africa
Source: CMSA, 2022
HRH and digitisation
Technological innovations may radically reshape the health sector, as evidenced by the creation of a fully virtual care facility, where health care personnel exclusively provide ‘telehealth’ services to patients, whereby medical advice and provision is given remotely through telecommunication technologies62. Advances in this field have also been driven by the COVID-19 pandemic. The National Digital Health Strategy for South Africa (2019–2024) mentions development of a Human Resource Information System (HRIS) to provide information necessary to support the health workforce. The HRIS aims to address the availability, completeness and quality of health workforce data63
Health care organisations will need to account for a wide range of implications related to technological advances, including the virtual delivery of services and the integration of robotics and Artificial Intelligence. However, the health sector must evaluate the added benefits of technology for patients and workers and enhance its usefulness through improved policy and practice. While health technology can contribute to cost containment, it has added to health care expenditure growth in recent years in OECD countries. Evidence of the effectiveness and utility of new technologies is not always clear, and policy-makers must balance innovation with value62
National HRH strategic planning: 2020–2030
South Africa’s commitment to attaining UHC for all its citizens through NHI recognised the need for adopting a strategic approach to HRH which is critical to HRH-related reforms. Sufficient numbers of well-skilled, enabled and supported health workers are central to the achievement of an affordable, accessible and quality health care system for all as envisaged in the NHI. Thus, a Ministerial Task Team was constituted in 2019 which in collaboration with the NDoH and in consultation with stakeholders delivered the28 2030 Human Resources for Health Strategy. Its release by the NDoH sets out the overall vision, goals and actions required to address persistent issues of inequity and inefficiencies in the health workforce. The Strategy provides insights on the numbers of health workers of different categories needed to provide for health promotion and disease prevention, and curative, therapeutic, rehabilitative and palliative services. It informs the training and education reforms that are needed in South Africa’s public universities, nursing colleges and health worker training institutions to supply adequate numbers of all cadres of the health workforce, from CHWs to sub-specialists28.
The Strategy laid down five basic HRH strategic goals28:
Goal 1: Effective health workforce planning to ensure HRH is aligned with current and future needs.
Goal 2: Institutionalise data-driven and research-informed health workforce policy, planning, management and investment.
Goal 3: Produce a competent and caring multidisciplinary health workforce through an equity-oriented, socially accountable education and training system.
Goal 4: Ensure optimal governance; build capable and accountable strategic leadership and management in the health system.
Goal 5: Build an enabled, productive, motivated and empowered health workforce.
The Strategy concludes with commitments to work immediately to:
• Mainstream gender and ensure diversity so that all health workers feel they belong and are treated with dignity, recognising that the health workforce must feel and be safe and treated fairly. This includes integrity in human resource practices, reasonable workloads, rapid recruitment, effective occupational health and wellness programmes and the necessary resources to perform their roles.
• Revise rural recruitment and retention strategies required to ensure that South Africa achieves its health system goal of equity in access to health professionals.
• To implement a shift in organisational culture and strategies to boost morale and give effect to the commitment to caring and quality. This should be rooted in competency frameworks and a more effective performance management and development system that facilitates full productivity from all health workers.
• Embark on an NDoH review of RWOPS, its interpretation, application and management.
• Strengthen the HRH function in the NDoH and conduct an economic analysis of the costs and benefits of internship and compulsory community service programmes, and the cost of employment of health professionals.
• Have the health sector work more closely with other sectors of government impacting on the practice environments of health workers (e.g., their conditions of service, living and working arrangements and safety).
Nursing Strategy
The strategy was launched in March 2020 and coincided with the declaration of 2020 as the International Year of the Nurse and Midwife, and the launch of the first ever report on the State of World Nursing 2020 by the WHO. Nursing and midwifery being at the forefront of managing the COVID-19 pandemic has highlighted the need for dedicated attention to and decisive action towards the plight of this professional workforce, as nurses are the backbone of any health care system. The disease burden has placed an additional stress on nursing. Increasing nurse turnover is widening the patient‐to‐nurse ratio, adding to workload and leading to a deterioration in the quality of care and patient satisfaction and health care outcomes64. The turnover of nurses in South Africa is not known, but recruitment of younger nurses and succession planning require attention.
The National Strategic Direction for Nursing Education and Practice: A Road Map for Strengthening Nursing and Midwifery in South Africa (2020/21–2025/26) was released by the NDoH in 202065. The Strategy’s overall objective is to harness nursing education and practice in support of UHC and the vision of the National Development Plan 2030 for ‘a health system that works for everyone and produces positive health outcomes’. It seeks to optimise nursing workforce planning, embrace digital technologies for education and clinical practice, as wellas advance socially accountable education programmes and systems, leadership and governance towards better nursing services.
The Strategy65 is underpinned by the need to:
a) Provide a framework for organising and coordinating the nursing workforce contribution towards the goals of UHC against the backdrop of the 2030 Human Resources for Health Strategy;
b) Build on gains made in the implementation of the recommendations of the previous nursing strategic plan that was mostly focused on nursing education; and
c) Enable a focus on the implementation of core HRH-relevant strategies to the nursing sector with targets and measurable outputs.
Conclusions and way forward
This chapter has provided evidence of important achievements in HRH in the past quinquennium, but has also shown up the fault lines in HRH today and what is needed to gear HRH in the next quinquennium for better availability of HRH and UHC.
The HRH Strategy 2030 ends with a detailed five-year Strategic Plan that focuses on key implementation activities, for the period from 2020/21 until 2024/25 and this should be the core of the way forward on HRH in South Africa. The Strategy highlights the specific actions needed to achieve each of its five goals and should be the central focus of HRH development for the next five years.
Key focus areas are:
• Coordination: Coordinated efforts from all stakeholders will be required to support implementation of HRH plans. Better coordination between the NDoH, the Department of Higher Education and Training, National Treasury, provincial departments, professional bodies and training institutions will be needed as will the financial instruments. Furthermore, engagement between the public and private health sectors along with social partners and with the Ministry of Employment and Labour will be required. Key to the way forward is:
• Planning: For more effective and comprehensive HRH planning, a functional National Health Workforce Analysis and Planning Function should be established to institutionalise and strengthen planning. It should draw on national and international health workforce planning expertise, including labour market analysts.
• Information driven: HRH planning and policy-making should be information driven using data from various sources such as PERSAL, health professional council registers (HPCSA, South African Nursing Council (SANC) and South African Pharmacy Council (SAPC)), District Health Information System (DHIS) and WHO National Health Workforce Accounts. This will create the data science opportunities for more predictive and intelligent analytics and decisions.
• Health workforce education: Globally, South Africa’s health education and training system is one of the most advanced and sophisticated. However, the existing health workforce supply pipeline is not fully configured and does not support optimum skills mix of the health workforce. Curriculum realignment with population health needs, specifically of vulnerable, under-served and rural and remote populations, is needed to lead changes towards transformative and sustainable outcomes.
• Leadership and management: A major investment is needed in leadership and management development. Performance standards for HRH leadership and management need to be institutionalised, revitalised continuously, and applied at every level of the system. The HRH regulatory structures need revitalisation to ensure good and accountable governance (e.g. HPCSA, SANC and SAPC). Strengthened systems of oversight of key professional regulatory bodies are needed, as is an effective Forum of Statutory Health Professions Councils.
• Conditions of service and positive workplaces: Positive conditions of service and workplaces to ensure the health, safety and well-being of the health workforce are fundamental drivers of quality health care and the overall performance and efficiency of the health system. This must be a priority. As an initial step, mainstreaming gender and ensuring diversity at all levels would help to ensure that health workers are treated with dignity and fairness.
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